CALIFORNIA - APPLICATION FOR EMPLOYMENT

CALIFORNIA - APPLICATION FOR EMPLOYMENT

IMPORTANT NOTICE: This is a very significant document. You should use care as you complete it. Answer each item accurately and completely. Failure to do so may result in you not being considered for a position. In addition, if inaccurate or omitted information is discovered after your employment has begun, your employment may be terminated.

Today's Date: ____________ PRINT your full name:________________________________

If you have ever used a name other than your current name for work or education purposes, list all previous names you have used: ______________________________________________________ (Note: This information is necessary for verification of your prior work and education history)

Present Address:

_____________________________________________________________________________

Street,

Apt. #

City

State

Zip

Home phone: _____________________________Are you at least 18 years old?

Are you authorized to work in the United States? _________

Position desired: ________________________ Date you can start: _______________

Are you available to work full time? _________

Are you employed now? ________ May we inquire of your present employer? _________

Have you ever applied to, or worked for Talley, Inc. before? Yes or No

If so, where? ____________________________ When? ______________________

EDUCATION: Circle highest grade completed 8 9 10 11 12 13 14 15 16 16 +

Did you graduate high school? _________ Did you graduate college? _________

List degrees earned _______________________________________________________________

Schools attended _________________________________________________________________ _______________________________________________________________________________

EMPLOYMENT HISTORY: List current/former employers, most recent first. REVISED 010118 CALIFORNIA APPLICANTS ONLY

Employer Name & Address

Start Date

End Date

Start Job Title

End Job Title

Description of Last Job Duties

Supervisor's Name

OK to Contact? Exact Reason for Leaving

Employer Name & Address

Start Date

End Date

Start Job Title

End Job Title

Description of Last Job Duties

Supervisor's Name

OK to Contact? Exact Reason for Leaving

Employer Name & Address

Start Date

End Date

Start Job Title

End Job Title

Description of Last Job Duties

Supervisor's Name

OK to Contact? Exact Reason for Leaving

Employer Name & Address

Start Date

End Date

Start Job Title

End Job Title

Description of Last Job Duties

Supervisor's Name

OK to Contact? Exact Reason for Leaving

REVISED 010118 CALIFORNIA APPLICANTS ONLY

HISTORY OF UNEMPLOYMENT:

Please list any periods of more than one month since you left school or during the last ten years during which you were not employed. _______________________________________________________________________________

_______________________________________________________________________________

PERFORMANCE OF JOB RELATED FUNCTIONS:

Are you able to perform the functions of the job for which you are applying with or without accommodation? Yes or No _________.

If requested, are you available to work (check as many that would apply):

____ weekends

____ evenings

____ days

____ overtime

SERVICE RECORD:

Branch of military service: __________. Enter date: _________, Discharge date: _________

REFERENCES:

Please provide the names of three persons you have known for more than one year who are not

related to you.

NAME

ADDRESS

PHONE

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Talley, Inc. is an Equal Opportunity Employer. It is the policy of Talley, Inc. from recruitment through employment and promotion and in any decision regarding termination of employment, to provide an equal opportunity to each employee at all times without regard to race, color, religion, sex, age, national origin, marital status, sexual orientation, political belief, physical disability or history of mental disorders (except where physical or mental abilities are a bona fide occupational requirement).

REVISED 010118 CALIFORNIA APPLICANTS ONLY

AUTHORIZATION - IMPORTANT

PLEASE READ CAREFULLY AND INITIAL EACH PARAGRAPH BEFORE SIGNING

I declare under penalty of perjury that the facts contained in this application or any resume or other

documentation submitted by me are true and complete to the best of my knowledge. I understand

that any false information or significant omissions will disqualify me from further consideration for

employment, and will be justification for my dismissal from employment if discovered at a later

date.

_________ Initials

I authorize the investigation of all statements contained in this application and any accompanying documentation provided by me and further authorize any person, employer (except as expressly noted to the contrary), and organization identified in this application form to provide the company with records, information and opinion that may be useful in making a hiring decision. I release all informants from all liability for any damage that may result from furnishing information and opinion to you provided that such information and opinion is truthful or made in good faith.

_________ Initials

I give permission for a pre-employment drug/alcohol screening exam and, if the company makes a conditional job offer, I give permission for a complete employment physical examination. I also consent to the appropriate release of any and all medical information, as may be deemed necessary.

_________ Initials

I understand that, if hired, I may not hold other employment, nor engage in other activities, that

create a conflict of interest with my position with the company.

_________ Initials

If I become employed, in consideration of my employment, I agree to comply with the rules,

regulations, policies and procedures of the company.

_________ Initials

If I become employed, in consideration of my employment, I agree that my employment will be at-

will, and may be terminated with or without cause, and with or without notice, at any time at the

option of myself or the company. Only Board of Directors of Talley, Inc. have the authority to

enter into an employment agreement for a specified period of time or for termination only for cause,

and any such agreement must be in writing. I understand and acknowledge that this constitutes the

entire agreement between me and the company regarding the term of my employment and

supersedes any other oral or written agreement.

_________ Initials

If offered employment, I understand that a condition of employment is to agree to the Company's

problem resolution procedure which includes an agreement to arbitrate as a final and binding step,

and I agree the process of my becoming employed will not be complete until I have signed all

employment documents.

__________Initials

Signature: _______________________________ Date: _________________

REVISED 010118 CALIFORNIA APPLICANTS ONLY

VOLUNTARY SELF-IDENTIFICATION INFORMATION

Name: (Please Print) _______________________

Date: ___________________

Position Applying For: _____________________

Referred By: ____________

PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS FORM

Talley, Inc. is subject to certain non-discrimination and affirmative action record keeping and reporting requirements, which require that we invite applicants to voluntarily self-identify their race/ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable federal laws, executive orders, and regulations. Submission of this information by you is voluntary. This information will not be used in any way for employment related decisions.

APPLICANTS IDENTIFYING THEIR GENDER AND RACE/ETHICITY

GENDER CLASSIFICATION

______ Male ______ Female

RACE/ETHICITY CLASSIFICATION (AS DEFINED BY EEOC)

______

Asian - (A person having origins in any of the original peoples of the Far East,

Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China,

India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and

Vietnam.

______

Black or African American - (A person having origins in any of the Black racial

groups of Africa)

______

Hispanic or Latino White - (A person of Mexican, Puerto Rican, Cuban, Central

or South American, or other Spanish culture or origin, and of the white race)

______

Hispanic Non-White - (A person of Mexican, Puerto Rican, Cuban, Central or

South American, or other Spanish culture or origin, and of any race other than white)

______

American Indian or Alaskan Native - (A person having origins in any of the

original peoples of North America and South America, including Central America,

and who maintains tribal affiliation of community attachment.

______

White - (A person having origins in any of the original peoples of Europe, North

Africa, or the Middle East.)

______

I choose not to self-identify

SIGNATURE: ___________________________DATE ___________________

REVISED 010118 CALIFORNIA APPLICANTS ONLY

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